Download BLADDER CANCER

URO ONCOLOGY
DONE BY:
SHATHA MUQBIL
SHAMS KADHIM
ANATOMY:
The bladder is an extraperitoneal muscular urine reservoir that lies
behind the pubis symphysis in the pelvis .
The ureters, which transport urine from kidney to bladder, approach
the bladder obliquely and posterosuperiorly, entering at the trigone
(the area between the interureteric ridge and the bladder neck).
The bladder neck serves as an internal sphincter.
In males, the seminal vesicles, vas deferens, ureters, and rectum
border the inferoposterior aspect of the bladder. Anteriorly there is
space filled with fibroadipose tissue and the prevesical fascia. The
dome and posterior surface of the bladder are covered by parietal
peritoneum, which reflects superiorly to the seminal vesicles and is
continuous with the anterior rectal peritoneum.
In females, the posterior peritoneal reflection is continuous with the
uterus and vagina.
ANATOMY:
BLADDER CANCER:
Almost all bladder cancers originate in the urothelium, which is
a 3- to 7-cell mucosal layer within the muscular bladder.
Squamous cell carcinoma of the bladder can involve multiple
sites; however, the lateral wall and trigone are more commonly
involved. 90% of bladder cancers are TCC. In developing
countries—particularly in the Middle East and Africa—the
majority are SCCs, and most of these are secondary
to Schistosoma haematobium infection
BLADDER CANCER:
The incidence of bladder cancer increases with age, with the median
age at diagnosis being 65 years; & rarely diagnosed before age 40
years.
Bladder cancer is about 3 times more common in men than in women.
The incidence of bladder cancer is twice as high in white men as in
black men in the United States. However, blacks have a worse prognosis
than whites.
Causes:
• Tobacco smoking is the main known contributor; & associated with
over half of cases in men and one-third among women.
• occupational exposure in the workplace to carcinogens such
as benzidine & naphthylamine, Occupations at risk are bus drivers,
rubber workers, motor mechanics, leather (including shoe) workers,
machine setters, and mechanics. Hairdressers are thought to be at risk
as well because of their frequent exposure to permanent hair dyes.
•It has been suggested that mutations at HRAS, KRAS2, RB1,
and FGFR3 may be associated in some cases.
CLINICAL PRESENTATION:
BY HISTORY:
• painless gross hematuria (8090%)
MALAGNANCY UNTIL PROVED
OTHERWISED
• Irritative bladder symptoms :
dysuria, urgency, or frequency of
urination (20-30%)
may be related
to more advanced muscleinvasive disease, carcinoma in situ
(CIS) is the more likely cause
•pelvic or bony pain, lowerextremity edema from iliac vessel
compression, or flank pain from
ureteral obstruction
THIS INDICATE A MORE ADVANCED
DISEASE
BY EXAMINATION:
typically nothing significant during a
physical examination. In rare cases,
a mass is palpable during
abdominal, pelvic, rectal, or
bimanual examination. A bimanual
examination may be considered part
of the staging of such lesions
Attention to the anterior vaginal wall
in women and the prostate in men
may reveal findings that suggest
local extension of bladder cancer.
Assessment of fixation of the bladder
to the surrounding pelvic sidewall is
also important when planning
definitive management for locally
advanced tumors that may not be
surgically resectable.
DIAGNOSIS:
Approach Considerations
Urine studies include the following:
•Urinalysis with microscopy to detect hematuria or infection
•Urine culture to rule out infection, if suspected
•Voided urinary cytology: is extremely valuable and is often the test used for
diagnosis.
IT is most helpful in diagnosing high-grade tumors and carcinoma in situ (CIS).
Low-grade, noninvasive tumors may be missed by routine cytologic analysis
.
•Urinary tumor marker testing may help in the early detection and prediction
of urothelial carcinoma. however, no urinary assay has been shown to
effectively replace urine cytology and cystoscopy.
DIAGNOSIS:
Imiging:
•Computed tomography (CT) scans of the abdomen and pelvis
with contrast are recommended.
• magnetic resonance imaging (MRI) and renal
ultrasonography.
•Few US centers still perform intravenous pyelography (IVP) for
upper tract imaging.
The bladder urothelium is not well visualized with routine
imaging studies, including CT scanning and MRI. Small tumors
are easily missed on images produced by these modalities.
Irregular areas on images, which may appear to represent
mucosal abnormalities, are often artifacts of incomplete
bladder filling; delayed images following contrast administration
can better visualize actual filling defects. CIS is not visible on
images from any current radiographic study
DIAGNOSIS:
Cystoscopy:
Is gold standard for detecting bladder
cancer, but it is invasive and relatively
expensive. Moreover, visibility can be
reduced by bleeding, and flat
urothelial lesions such as CIS may be
difficult to distinguish from normal
bladder tissue. Use of adjunctive
endoscopic techniques may improve
the accuracy of cystoscopy.
DIAGNOSIS:
DIAGNOSIS:
TREATMENT:
 Tis
Complete TURT + Intravesical BCG
 Ta (Single)
Complete TURT
Ta (Multiple) Complete TURT + Intraveiscal chemotherapy
 T1 Complete TURT + Intravesical Chemotherapy
 T2 – T4
 Any
1) Radical Cystectomy
2) Neoadjuvant Chemotherapy + Radical Cystectomy
3) Radical Cystectomy + Adjuvant Chemotherapy
T , N+ , M+
Systemic Chemotherapy followed
by selective surgery
TREATMENT:
BCG
Mitomycin-C
Thiotepa
Instilled directly into the Bladder via a Urinary Catheter to avoid
morbidity of systemic administration.
I.
II.
III.
Adjunctive : at time of TURT to prevent implantation
Prophylactic : after complete TURT to delay recurrence or
progression
Therapeutic : after Incomplete TURT to cure residual tumor.
To improve efficacy :
1.
2.
3.
4.
Avoid Air instillation
Increase contact time
Increase drug conc. By decreasing fluid intake
Changing patient’s position during therapy
TREATMENT:

Is the initial treatment for most bladder cancers .

Patient should be checked every 3 months after
the operation for recurrence.
TREATMENT:

The Gold Standard for Muscle-Invasive CA.
Includes removal of :
In Male : Bladder ( &its surrounding fat and peritoneal attachment)
Prostate
Seminal Vesicles
In Female : Bladder ( &its surrounding fat and peritoneal attachment )
Ovaries
Uterus
Cervix
Anterior Vaginal Vault.